Why Primary Health Care implementation will succeed this time

It is not about the drill, but about the holes - that is why Primary Health Care Redesign will work this time in Saskatchewan.  Let me explain ...

I heard this metaphor about a drill and holes that I think applies so well to the Primary Health Care (PHC) context in Saskatchewan.   Your goal is represented by holes in a wooden board and your process is represented by the drill and drill bits.

Drill and drill bits representing the process

or the HOW we do something

Pegboard with holes representing the goal or WHAT we want to achieve.





In June 2002 the Saskatchewan Ministry of Health released a document "The Saskatchewan Action Plan for Primary Health Care".  The goal was clear in the first paragraph of the document:

"The principal goal of the health system is to maintain and improve the health of the people it serves. In Saskatchewan we have been striving for a system that is effective, responsive and sustainable in the longer term. In order to achieve these broad goals we must change how we think about primary health care services, how those services are provided and by whom, and how they relate to the more specialized acute care system."


So why did this plan fail ?  Why are we are talking about Primary Health Care Redesign in 2011 ? Why would an engaged family physician who wanted to implement most of the concepts (like collaborative, team based delivery of care; looking after a whole population of people; improving access and quality improvement) not participate in the implementation ?

The answer is very simple: From 2003 until recently, the Ministry of Health focussed on the drill and drill bits (process) and not on the holes (goal).  They basically said that family physician practices had to qualify to become a Primary Health Care site by doing 2 things: 1) They had to go on an alternate funding model of payment for physicians (as opposed to fee-for-service) and 2) They had to have a Nurse practitioner as part of the team.  Now this might be and over simplification, but although there is nothing wrong with either concept - this was the main reason why most family physicians did not sign up, because the focus was on the process (the drill and drill bits or the HOW).  I am convinced that almost every single physician in the province agreed with the Ministry of Health on the goal of the Saskatchewan Action Plan for Primary Health Care (What the holes in the board should look like.)

Unfortunately this led to a lot of family physicians being marginalized, because they did not want to join these Primary Health Care sites.  Funding for projects were only available to these approved sites and family physicians could only be part of it, if they signed on the dotted line ...  It also caused unnecessary tension between nurse practitioners and family physicians.

In the graph above you can see that from the previous implementation in 2003 until 2011 it was only "approved PHC sites" managed by health regions that got any funding for projects under the PHC umbrella.  Other family physician practices who did not qualify were left on their own regardless of how many quality initiatives for primary care they participated in or how many desirable elements they implemented in their practices.

I strongly believe that for the process to succeed this time, the Ministry of Health  has to focus on WHAT they want to achieve and be enablers towards this goal and leave the HOW to the frontline health care workers, communities and patients.  Every community should be encouraged to build their service delivery model from the ground up instead of being told how to do it, because the delivery teams, funding models and projects might vary significantly between communities.  The sites should qualify for support and funding based on their goals and measurements along the way.  It should also not be an "all-or-nothing" way of qualifying to be a Primary Health Care sites.  Every family physician practice in Saskatchewan should be seen as a Primary Health Care site.  The more desirable elements these practices implement, the more support or funding they should receive.

If you only have a few Primary Health Care sites and you make them as efficient as you can to deliver the highest quality service it will still not benefit the majority of the patients in the province who don't have access to them.  This is the reason why the Ministry of Health and health regions have to see all family physician practices as Primary Health Care sites and then enable them to implement as many desirable elements as possible, because this is the only way that all the patients in the province will have access to high quality primary health care.

 So instead of telling family physicians that they should 1) go on alternate funding and 2) have a nurse practitioner on the team, the approach should rather be to encourage them to implement as many of the above mentioned desirable elements.  Then instead of penalizing family physicians for not being primary health care sites (by not giving any support or funding), the ministry should reward practices with support and funding for projects according to their level of participation.  

You will note that funding models for physician payments is not on the list and that is because one should first put a system in place that works and achieves preset goals and then see what funding model for physician payment will be the best fit.  

You will also note that having a Nurse Practitioner on the team is also not on the list, but rather - team based care delivery with most appropriate provider for most appropriate care.  It should depend on patient needs, the community and available resources who is on the team.  

Having physicians on alternate funding and having nurse practitioners on the team would be an option and not a prerequisite.

There are many ways to drill a hole and as long as the focus is on the hole and not on the drill and drill bits, we will get there.

I believe PHC Redesign in Saskatchewan will succeed this time, because the Ministry of Health under the lead of Assistant Deputy Minister of Health, Ms Lauren Donnelly, (who has the Primary Health Care portfolio) seems to have the focus on the goal this time and is wiling to have patients in partnership with their providers and communities come up with the solutions from the ground up rather than being told what to do.  The challenge for the Ministry is going to be to find the best way to be an enabler and to remove any obstacles that prevent practices from implementing desirable elements in their practices.  What the support is going to be and how it will be distributed will determine the success.  

If we (administration and providers) don't get it right this time we will only have ourselves to blame, because there is a healthy combination of factors that can make this process a success.  We have a Ministry of Health that seems to want to listen and act on input from all stake holders. This was seen in a few information gathering sessions (Chronic disease, Physician engagement, Community engagement and First Nations involvement) held in 2010/2011.  We have many family physicians that have been waiting for more flexibility and options in Primary Health Care so that they can be part of it.

I believe in the quote that "No major health transformation can succeed without significant physician leadership and input..."  and we have a lot of physician leaders that are willing to step up and make this happen.  The Deputy Minister of Health, Mr Dan Florizone has echoed this sentiment on various occasions.  The relationship between physicians and the Ministry of Health is very healthy at the present time.  We have communities that want to get involved.  We have a clear mandate from the patients in the province as was seen in the Patient First Review.

I do sincerely believe that the "tipping point" is near.  As Malcolm Gladwell said in his book, The Tipping Point : "The tipping point is that magic moment when an idea, trend or social behaviour crosses a threshold, tips, and spreads like wildfire." ...  Little causes can have big effects and change does not always happen gradually, but sometimes it happens at one dramatic moment when the right mix of factors are present to reach the "tipping point".

We can draw a graph of what the level of participation of providers on the horizontal axis vs the level of support from administration (health regions and the ministry) on the vertical axis would look like.  The red box shows the practices that are considered Primary Health Care sites:

Looking at the graph above one will recognize that administration (Ministry of Health and health regions) are working on the vertical axis by providing support and being enablers.  Family physician practices which would ALL be considered PHC sites are represented on the horizontal axis.  Administration will need to find ways to remove obstacles and enable family physician practices to implement more desirable elements into their practices.  Family Physician practices need to look at the desirable elements that they have not incorporated yet and see if they can move to the right on the horizontal axis.  While doing all of this the most important thing will be measurements so that we can see where we are making a difference.  Measures need to cover all three aspects of the Triple Aim -

1. Improve the health of the population;
2. Enhance the patient experience of care (including quality, access, and reliability); and
3. Reduce, or at least control, the per capita cost of care.

I have used every opportunity to explain this model to officials in the Ministry of Health and so far I get the impression that they have accepted it and is willing to use this model for physician engagement in Primary Health Care Redesign.

I do believe that by enabling family physicians and by giving them the opportunities and flexibility to implement desirable elements into their practices this model will spread throughout the province and more patients will have access to high quality primary health care when they choose so ...

I am moving my practice as far to the right on the horizontal axis as I can with available resources and I hope the ministry of health and my health region will enable me to do so.  So whether you are an administrator or health care provider, are you going to be an enabler or an obstacle ?